Bell et al reported that withdrawal of pregnant women from opiates was not harmful because they reported only 2 fetal deaths and no other complications. However, no monitoring of maternal or fetal stress was done.

That the fetus can survive withdrawal does not mean that it survives unharmed. Mothers and fetuses can survive horrific stressors (eg, the Dutch War Famine, during which babies seemed to survive maternal starvation, but later many developed diabetes, cardiovascular disease, and schizophrenia).

Acute opiate withdrawal is a known physiological stress, causing a prolonged surge in corticosteroids. Corticosteroid excess signals poor environmental conditions from mother to fetus, causing rapid modification of neurotransmitter systems and transcriptional machinery and triggering permanent modifications of behavior, brain morphology, and neuroendocrine function. In addition, acute catecholamine excess (both maternal and fetal) during withdrawal causes placental vasoconstriction and risks of hypoxia and growth restriction.

Ethical concern for fetal safety has limited human studies of acute and chronic withdrawal. Our goal as physicians is to protect the fetus from the noxious effects of stress, not to see how much stress it can survive. This report declares, without any stress monitoring, that abrupt jail withdrawals or disturbingly rapid 5-8 day medical withdrawals pose no harm for the pregnancy, ignoring potential harms the biology of withdrawal poses for the fetus. All these babies were put at risk for developmental problems.

Additionally, anxiety and psychological stress have long-term adverse effects on neonatal health. These mothers were living in the state of Tennessee where opioid use in pregnancy and neonatal withdrawal are criminalized, which raises issues of coercion as women must withdraw or risk losing their baby. We are told nothing about how much these mothers suffered.

This paper reflects the ethical issues that result when extremist politics influences medical care. Witness the authors’ apparent approval of abusive jail withdrawals, during which 2 fetuses died, because “acute detox in pregnancy does not result in a large number of poor outcomes.”

The fact that physicians continue to ignore evidence of fetal stress from withdrawal dictates that more research into the biology of maternal and fetal withdrawal (eg, stress hormone levels and intensive fetal biophysical profiling) and effects on development be given high priority before more babies are exposed to blind procedures that resemble roulette with the fetal brain.